End of Life Care

Question 1

EoLC relates to a person expected to die within how long?

Answer 1

within the next 12 months

Question 2

read JRCALC guideline ‘End of Life Care’

Answer 2

do it

Question 3

Review the Gold Standards Framework Prognostic Indicator Guidance (2006). Briefly consider the reliability of tools such as the GSF PIG.

Answer 3

do it

Question 4

pain assessment

Answer 4

VAS / FLACC

Abbey Pain Scale

Any recent changes in pain?

When, how & what were those changes?

Number of breakthrough (rescue) doses?

Non verbal cues?

Ask family / carers

consider what medications the patient is taking and their strengths.

Question 5

Common EoL Symptoms

Dyspnoea

Answer 5

As a result of disease

as a result of treatment

as a result of other causes:
psychological: fear, anxiety.
Pre-existing cardiac or respiratory.

Question 6

Reversible Oncological emergencies

Answer 6

Spinal Cord Compression
Superior Vena Cava Compression
Neutropenic Sepsis
Hypercalcaemia

Question 7

Management of:

Malignant Spinal Cord Compression

Answer 7

TIME – potential neurological damage limited by rapid response
Attempt to call oncology / SPCT for advice
Analgesia
Extrication
- Limit movement
- Position – spine in neutral alignment

Question 8

signs and symptoms of:

Malignant Spinal Cord Compression

Answer 8

Cervical: arm weakness, +/- pain, +/- power loss

Thoracic: Radicular pain (radiating into legs)

Lumbar: lower back pain, leg pain +/- weakness,
decreased anal tone, bladder retention

Question 9

Signs and symptoms of:

Superior vena cava obstruction

Answer 9

Single most reliable sign is elevated JVP, non pulsatile.

Early: periorbital oedema, facial swelling

Late: Engorged H&N veins, increased oedema, plethora (excess of body fluid/blood), cyanosis

Severe: Headache, blurred vision, altered mental state, seizure

Question 10

Management of:

Superior Vena cave Obstruction

Answer 10

Loosen clothing

Airway management

Sit upright/elevate head

Oxygen as per guidelines

Keep calm - ?patients own benzodiazepine

Question 11

Signs and symptoms of:

Neutropenic sepsis

Answer 11

7-14 days post chemotherapy treatment BUT can be up to 6 weeks

Minor illness/feels generally unwell

Signs and symptoms of infection

pyrexia >38 requires urgent treatment

remember UKONS tool

Question 12

management of:

Neutropenic sepsis

Answer 12

high index of suspicion

Call treatment unit

Follow sepsis guidelines

Question 13

Signs and symptoms of:

Hypercalceamia

Answer 13

metastasis in bones: increased osteolysis (destruction of bone) increases calcium release

Hormone related

Think breast, lung or renal cancers with metastatic disease

Bone pain

Abdo pain, N&V, constipation

Renal stones, polyuria, polydipsia, dehydration

Fatigue, lethargy, anorexia, cardiac arrhythmias

VERY HARD TO DIAGNOSE IN THE PRE HOSPITAL SETTING

Question 14

To convey or not to convey

Answer 14

Is it an EoLC reversible condition?

Where on their illness journey is the patient?

Can symptom relief be provided at home?

Has there been a change in social situation?

Could this be the dying phase?

HAVE YOU MADE A BEST INTERESTS DECISION?

WHAT DO THE SPECIALISTS ADVISE?

SHARED DECISION MAKING IS KEY: GP, APP, CHUB, 111, Hsopice, Patients palliative team

Question 15

Medications administration

Answer 15

Paramedics CANNOT change / adjust a syringe pump

Paramedics CAN administer anticipatory medications as long as the medicines and authorisation chart are available in the home

The usual route of administration is subcutaneous (S/C)

Paramedics CANNOT accept verbal orders

Question 16

Anticipatory Medicines

Answer 16

A signed authorisation chart must be present and authorised by an independent prescriber.

Includes information on each drug’s:

• Indication
• Dosage
• Frequency

Question 17

Paediatric expected death guidance

Answer 17

EBS must be informed

Follow the child’s care plan if in place

Consult the child’s clinical team

Question 18

Welfare for clinicians

Answer 18

Triggers
Bereavement by Exposure
Debriefing
PD33

STOP for 5 minutes
S: summarise the case
T: things that went well
O:oppurtunities to improve
P: points to action and responsibilities

Question 19

Documents to review

Answer 19

Review LAS Guidance ‘Recognition and Management of Dying’

Review the subcutaneous medications administration video

Watch the AACE webinar ‘Compassionate Conversations’ (Start at 7 mins)

Read the JRCALC guidelines, ‘End of Life Care.’

Review the Gold Standards Framework Prognostic Indicator Guidance (2006). Briefly consider the reliability of tools such as the GSF PIG.

Review the LAS Guidance – ‘Medication at the end of life’.

Review the JRCALC guidance – ‘Morphine Sulfate for the Management of Pain in Adults at the End of Life’

Review the JRCALC Guidance – ‘Covid-19: Managing Symptoms (Including at the End of Life) In the Community’.

Review the LAS Guidance – Advance Care Planning.

Read the Mental Capacity Act Code of Practice.

Watch the ACP video on FB Live.

Question 20

Things to help your decision making

Answer 20

A cancer diagnosis is not the only palliative one
Pause and think…… could it be EoLC?
Look for notes / CMC
Read notes
Advice and information from CHUB
Always call the specialists - they are there to help you!!

Think about what is the most appropriate care for your patient